Help required on PTCA with stenting to LAD and LCX treatment.

My father (59 years,smoker) has recently complained of chest pain. As I understand (From the Advise of 3-4 doctors here in India and reading on internet), there are two options as a remedy:

(1) PTCA with stenting to LAD and LCX

I am getting mixed opinions here from the doctors . I would like to know which procedure is best for profile (59 years, smoker). I am putting the details of the angiogram report for your reference:

CORONARY ANGIOGRAPHIC DATA:

Procedure:     LHC done by RFA approach.

Findings :      LMCA       : Normal
                    LAD          : Type III vessel & Proximal is normal. Mid LAD has 70% stenosis.
                    Diagonals  : Normal
                    LCX           : Proximal LCX is normal. Mid LCX has 99% stenosis.
                    RCA          : Non dominant, small calibre vessel and diffusely diseased.

Angio Diagnosis: Atherosclerotic CAD Triple vessel coronary artery disease.

Final Diagnosis: IHD-Acute coronary artery syndrome triple vessel coronary artery disease.

I really appreciate the time you have taken to help me out. I thank you from the bottom of my heart.

[ed34]

I would have thought your Fathers pain is quite bad with a 99% occlusion in the LCX.
You don't say what the second option is, but I assume you will be refering to bypass.
With there only being two blockages, none of them 100%, and both in the middle of the vessels, I would opt for Angioplasty as the prefered option. Recovery is much quicker and will have far less impact on your Father.
I dont think the RCA is a real problem at this stage, but lifestyle changes will be required such as smoking, diet, exercise.
This is just my opinion and I am not a doctor.

[kenkeith]

Well actually there usually are 3 treatments available for CAD (medication, stenting and bypass).  If there is only chest pain as a symptom, and no shortness of breath and/or fatique, then if medication can relieve the chest pain, that would be the preferred option.  

The ICX may have developed a natural bypass so that area for blood/ oxygen may be adequate.  The 70% LAD can provide sufficient blood flow according the AHA/AAC guidelineds....I have 100% blockage of the LAD (collateral vessels provide a natural bypass), and I do quite well with medication...I did have have a stent 6 years ago in the RCA...I was not able to make a knowledgeable at the time and may not have needed the stent?!

Quit smoking and medication first option.  If your father still has symptoms, then stents, and if your father is still symptomatic then a bypass may be the only option.    

[ed34]

suraj228's Father has a 99% blockage in the middle of his LCX. This means only 1% is open and this is very small. It won't be long before it totally blocks and I don't believe life style changes or medication will have any change to the outcome of such a severe blockage. We could 'assume' he has developed collaterals, sure, but if he hasn't and this blockage ruptures he will need God on his side not to die as a result. This blockage is serious. You also know that not everyone has shortness of breath as a symptom of heart disease. When my LAD was only being fed by a few tiny collaterals I had no SOB problems. According to my cardiologist, the 100% occlusion I had in my LAD was unlikely to ever errupt. He said it forms heavy plaque at both ends, meaning the softer mass in the centre cannot increase and there is not sufficient blood pressure to move it. So maybe your case is the same as mine was, your 100% is nicely packed in the artery very tightly with thick plaque surrounding it. This 99% blockage is still open to rupture.
If that was my Father, I would not rely on medication because there is no magic tablet to remove occlusions, and I would not assume collaterals have formed and wait to see if I was right. That's just my personal opinion.

[kenkeith]

You have a point, but assumptions are not reality.  Therapy is almost always a matter of probability and treatment accordingly.  There will almost always be exceptions, but effective treatment shouldn't be based on what the most unfavorable condition could be, but treatment should be based first with the probability of the most favorable condition.  I have been answering heart related questions going on 6 years, and I have come to believe there are many patients that have been unnecessarily treated radically when other options were are available.  I have not always had that opinion.  For a few years I believed a bypass was the only and best option so I have had both points of view.

QUOTE: "According to my cardiologist, the 100% occlusion I had in my LAD was unlikely to ever errupt. He said it forms heavy plaque at both ends, meaning the softer mass in the centre cannot increase and there is not sufficient blood pressure to move it. So maybe your case is the same as mine was, your 100% is nicely packed in the artery very tightly with thick plaque surrounding it".

I don't know what test measures thickness of plaque in the lumen and its probability not to break away...a ct scan increases risk of rupture based on the degree of plaque within the anatomy of the vessel.  The results of my ct scan had a written comment on the report that states there is blood flow into the stented area and an outflow so it is open and no evidence of restenosis.  I believe the degree of blockage within the lumen is measured by the volume of blood entering a lesion and the volume of blood exiting....subtract input from output and divide by input  will be the percentage of blockage.  Most probably the doctor just views and estimates.

If your collaterals feed into the distal side of the second  blockage,  that could increase gradient pressure and as a consequence the proximal pressure on the blockage could break through, and that would change the dynamics to the segment in question. But the heart cells distal to the first blockage may not be viable so it is difficult to envison how there could be blockage downstream to the 2nd blockage unless that blockage developed first and in that case it seems a bypass is the only option.

But the professionals who analyzed the vessels stated there was a stent option so that almost rules out a situation that you experience.  If medication opens the vessels sufficient enough to show good perfussioh with a stress test, then that may be the better option.  That's my opinion.

[ed34]

"I don't know what test measures thickness of plaque in the lumen"

It's down to experience. My Cardiologist has dealt with removing so many that he has a very good idea. With my blockage for example, several other cardiologists were telling him to give up when he had chipped away a depth of 2mm of plaque. He replied "I will be reaching soft material very soon" and he was spot on. I feel honoured being under this Cardiologist and having meetings with him because he has 30 years experience in angioplasty and is heavily involved in research. If this guy tells me 100% blockages are unlikely to break open, then I will believe him.

"If your collaterals feed into the distal side of the second  blockage,  that could increase gradient pressure and as a consequence the proximal pressure on the blockage could break through"
Well, I dont know if you have actually seen your angiogram. The blockage at the top of my LAD was nearly 2 inches long and the vessel around the occlusion was swollen beyond normal full capacity where the material was so packed. This pressure was created as the plaque formed at either end of the 100% blockage and the blood pressure
forced it inwards. You could see it would take incredible pressure to move that blockage, something blood would no way be able to provide.
Imagine a blockage forming. It forms within a normal wide vessel, not a narrowed one. This blockage when 100% will be larger than the normal dilated size of the artery. Now imagine the artery behind the blockage, much narrower now if supplied by collaterals. The pressure from the collaterals will have no chance in moving that blockage upwards
against blood pressure from the aorta. Also the pressure from the aorta will have no chance in shifting the blockage down the artery because the lower section will be basically wrapped around the end, helping to hold it in place.

"but treatment should be based first with the probability of the most favorable condition.  I have been answering heart related questions going on 6 years"
Well, I agree medication in a case such as this is the primary treatment, but short term until a decision is made on the way forward to remove such a dangerous occlusion. Of course you have to make the patient as comfortable as possible, and medication is the way to do this as a short stop. It doesn't matter to me how long someone has been answering questions, it depends on many factors. I know a man 70 years old who used to be a mechanic, but he wouldn't recognise an engine now if I opened a hood.
Look, I'm not trying to put you in an awkward position or make you feel uncomfortable, I just don't think medication is the answer for patients who have serious blockages waiting to explode. I believe you said in another post that you was advised to have surgery but you refused and opted to stay on medication. That was your opinion, and because it was a 100% blockage, you could be right. I could have stayed as I was with my 100% occlusion and kept taking beta blockers, but I am 48 and want a better life. I was sick of the restrictions. Now I just need the right artery sorted but the most dangerous one is now fully open and I can actually sleep better knowing it isnt blocked anymore.

[kenkeith]

You made a response that one can know the configuration of the plaque formation, and I stated I don't know of test that can determine the degree of plaque in the lumen, but a ct scan can determine tha amount of soft plaque.  Your reply is that a good cardiologist would know by experience when performing an operation.  Don't disagree, but what is the TEST!  If you know?

You are confused.  Medication is a good option for some people, and there is no way to remove an occlusion unless you are referring to roto rooter, and that often isn't an option.  I have been taking medication for going on 6 years for CAD, and it isn't meant to feel comfortable although that is the result of relief from symptoms, but all therapy for CAD removes symptoms...its not a cure.  

QUOTE: "Look, I'm not trying to put you in an awkward position or make you feel uncomfortable, I just don't think medication is the answer for patients who have serious blockages waiting to explode".

Your rhetoric doesn't make me uncomfortable. I have a very good understanding of heart issues, and how it relates to me, and with that exerience how it might relate to an individual in a similar situation.  And where do you get the idea blockages explode?  Blockages (coronary) prevent an adequate flow of blood to heart cells, and there are options to dilate the vessels medically or with a stent, and if necessary a CABG.

I don't understand your convoluted story regarding your interpretation of what you think the configuration of your particular vessels are...you sound confused to me, so I can't comment.

[ed34]

"Don't disagree, but what is the TEST!  If you know? "
Not just from an operation, but seeing it on an angiogram. There are no tests for many things in medicine so we can't always rely on that. A classic example is cancer. If a single cell or a few single cells break free from a primary site and attach to different areas of the body, there is no test for this. The only test is observing those cells using MRI once they have reproduced into a sufficiently sized tumour for detection and the smaller the tumour, supposedly the better chance of treatment which is not always the case either. Many Oncologists call on their own experiences. It would be nice if there was a magic machine which could test everything in the body, but this sadly isn't the case. The is why there are so many cases of misdiagnosis. Before patients get to see a consultant who specialises in a specific field, they have to get through the screening of a general Doctor. Those Doctors 'hopefully' point you in the right direction but in many cases they do not.

[ed34]

"You are confused."  A classic misdiagnosis
"Medication is a good option for some people, and there is no way to remove an occlusion unless you are referring to roto rooter"
Roto rooter is a company in the states dealing with the removal of tree roots. I am aware of technology known as a rotablator if that's what you mean. There are many other options apart from a rotablator. Lasers are used in many cases. When my blockage was removed the Cardiologist had to remove tiny pieces of plaque until he came across soft tissue to pass the catheter through. This meant bringing small pieces out of my body, one at a time. There are even safety nets to catch drifting plaque. A total occlusion doesnt necessarily have to be rotablated anyway. If the plaque is removed at one end, the remaining blockage can often be simply ballooned and stented. Not all blockages require the same treatment. There are many other devices available, but I'm not going to write a book on here.

[kenkeith]

QUOTE: "Roto rooter is a company in the states dealing with the removal of tree roots."

Your description of your large imbedded plaque may need a rotor rooter and that was my point.  I'm beginning to believe you are looking for sympathy and attention with your unbelievable stories regarding CAD...most of the time it doesn't make sense, and it is inconsistent with medical disorders and conditions.  

[ed34]

read my lips it's    " r o t a b l a t o r"

[Southern_woman]

Look ,,I had many blockages  and they were 90 to 98  % blocked,,no DR. ever
mentioned meds to cure this,,it takes a by -pass or stent,s to be on the safe side
I have been there, done that,and I am sure of what I,m saying.

[sn_joshi]

I have alredy place a question yesterday around 2pm the patient is my father M67 the result of engiography is 100% block in Mid LAD ,distal LAD retrograde filling through collaterals the blockege (100%) is between 2nd septal and 2nd diag.br. on LAD,
  I want to know that only angioplasty is requierd immediatly to solve the problem
father complaint for a little pain in heart near about reguraly

[kenkeith]

QUOTED ed: "Roto rooter is a company in the states dealing with the removal of tree roots."

A roto rooter unplugs drains with a flexible,  twisting motion as it moves down a drain.  Its merely a description of a process not the name of the procedure.  Its not an unusual expression.

[kenkeith]

QUOTE ed: "read my lips it's    " r o t a b l a t o r"

Typical smart-aleck remark.

[kenkeith]

Southern_woman QUOTE: Look ,,I had many blockages  and they were 90 to 98  % blocked,,no DR. ever mentioned meds to cure this,,it takes a by -pass or stent,s to be on the safe side I have been there, done that,and I am sure of what I,m saying.

>>Meds is not a cure, nor are any of the other two procedures (stent, bypass).  The available therapy only treats the symptoms.  There are a number of studies ( COURAGE study) that conclude there are no difference of any of the 3 treatments for an increase of longivity.  Experts on the heart forum confirm.
____________________________________________

QUOTE sn-joshi:
"I want to know that only angioplasty is requierd immediatly to solve the problem
father complaint for a little pain in heart near about reguraly".

There are situations that may require immediate treatment (emergency) with a stent implant or bypass. My situation is not unusual, and I have been treated with medication to treat angina (chest pains) occasionally (increase exercise tolerance).  I have 100% blocked mid LAD with collateral vessels and 72% blocked circumflex.  If you mean solve the problem, and the problem relates to angina (heart related chest pain), there can be relief of the problem with medication.  Medication dilates the vessels for better oxygenated blood perfusion.  A stent is a mechanical brace that holds the vessel open (could fail or restenosis), and bypass grafts a bridge around the blockage (graft could fail or block).  

Former president Clinton had a bypass 6 years ago (about the same time as my experience), and he has to have another interventional process....I have no symptoms and feel well.

[ed34]

Did you say in a post some time ago that your cardiologist recommended stenting or bypass? and you decided to stay on medication?  or am I confusing you with someone else?  I am surprised that a cardiologist would recommend leaving a 72% blockage. Maybe it's different in your country, but I know the UK has a fixed margin of 70%. Any
blockage 70% and above was quoted by my cardiologist to be seen as life threatening.

[kenkeith]

My first cardiologist stented a 98% occluded RCA, and did not stent the 72% blocked circumflex.  Several weeks later he wanted to stent the circumflex even though I was feeling great.  I never refused nor did I accept....I didn't get an answer why the cx  wasn't stented at the time of the RCA, and I never got an answer to what would be the benefit of a cx stent?  He left the state a couple of weeks later....the replaced cardiologist has never suggested a stent procedure going on 6 years.